A care plan on a patient with a cardiac, respiratory, gastrointestinal, or neurological primary diagnosis.Use of appropriate sources and APA format (in-text citations and a reference page) are required for all care plans. No abbreviations will be accepted.

CARE PLAN GUIDELINES

Use of appropriate sources and APA format (in-text citations and a reference page) are required for all care plans. No abbreviations will be accepted.

Completing a care plan on a patient with a cardiac, respiratory, gastrointestinal, or neurological primary diagnosis is strongly recommended.

Student Name: Date:
Patient Initials: Room #: Age: Admin. Date:
Sex: Height: Weight:
Ethnicity: Race: PrimaryDiagnosis:
Occupation (current or previous): SecondaryDiagnosis:
Allergies: Diet: Current SurgeryDate / Type (if applicable):
Fill out the above chart with the patient’s demographic and admission data.

History of Presenting Illness (Chief Compliant):

A narrative summary of the patent’s admission (i.e., admission date, presenting

signs and symptoms, reason for admission in the patient’s own words [i.e., “my stomach hurts”], and admitting medical and/or surgical diagnoses

Past Medical and Surgical History:

List your patients past medical and surgical history.

Diagnostic Testing (recently completed or to be complete):

Briefly describe any diagnostic test and discuss basic findings /

interpretations, if the test was already completed (i.e., Chest X-

ray, ultrasound, etc.)

Nursing Activities and Medical Equipment:

List nursing activities and medical equipment ordered for you patient and then

briefly discuss nursing care considerations for each [be sure to cite a source in APA format for nursing care considerations i.e., (Jones & Smith, 2012)].

Nursing Activities (i.e., ambulate as tolerated, blood glucose checks, wound care, aspiration precautions, and contact isolation)

Medical Equipment: (i.e., pneumatic compression boots, supplemental oxygen, chest tube, tracheostomy tube, mechanical ventilator, IV infusion pump etc)

Psychosocial Assessment:

Briefly describe Erikson’s Stage of Psychosocial Development (be sure to cite a source in APA format for Erikson’s Stage) that is relevant to your patient. Discuss your patient’s psychosocial assessment findings and then discuss whether or not the patient is successfully navigating the above identified stage.

Cultural Assessment:

Briefly describe key cultural concepts related to your patient’s ethnicity in terms of preferences, values, and beliefs. Discuss your patient’s cultural assessment findings and then discuss how these preferences, values, and beliefs may be incorporated in nursing care.

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